Coroner's Finding: NAPIER Ebony Simone

Contributing factors

• Failure to obtain Bradley Napier-Tucker's documented child protection history from New South Wales authorities
• Inadequate investigation of fractured femur in August 2011
• Failure to consult radiologists regarding age of femur injury
• Inadequate assessment of cannabis consumption and its impact on parenting capacity
• Failure to invoke mandatory drug assessment provisions under Children's Protection Act 1993
• Inadequate response to family disengagement from services
• Failure to identify domestic violence incident in September 2011
• Premature closure of Families SA file on 14 October 2011
• Failure to act on CAFHS concerns about lack of engagement in October 2011
• Ineffective inter-agency communication and coordination

Coroner's recommendations

1. Establish a nationwide child protection database immediately accessible across all Australian States and Territories to obviate need for specific interstate inquiries
2. Automatic transfer of guardianship, custody and parental responsibility orders between States and Territories where individuals move
3. Establish alert system when contact is lost with a child subject to child protection matter to notify all other State and Territory protection authorities
4. Health services immediately report detected drug abuse in family environments with children to Families SA Child Abuse Report Line
5. Thorough investigation into background of parents or persons in loco parentis must be essential element of child protection investigations, particularly where family comes from another State or Territory or parents are under guardianship of interstate Minister
6. Child Protection Service, Families SA and SAPOL recognise investigations comprise more than mechanical assessment of injury consistency; must consider background, propensities and intrinsic likelihood
7. Child Protection Service take into account medical opinions of all physicians including radiologists when conducting investigations
8. File closure authorisation only by officers superior to Supervisor rank in cases of physical harm to child, domestic violence, or reported disengagement from services
9. All other Families SA file closures reported to higher-ranking officer than Supervisor
10. Family disengagement from services immediately reported to Families SA with Families SA worker dispatched to home to investigate; written and verbal warning of potential legal action; continued regular monitoring
11. No file closure where family disengagement from health and other services has been reported
12. Full reassessment of manner in which health services and Families SA interact in child protection matters
13. Families SA implement systems for escalation of scrutiny where subject family reported as disengaged from services
14. Families SA instruct staff that file closure does not relieve Families SA of responsibility for child protection; implement system for continued monitoring of high-risk cases notwithstanding closure
15. Families SA introduce requirements ensuring matters not adequately managed due to lack of resources immediately drawn to Chief Executive's attention
16. Train staff of health services in specific child protection issues; encourage assertive engagement with families; report disengagement to Families SA as it occurs
17. Before closure of Families SA file, advise various service entities of intention to close
18. Regular formal inter-agency liaison meetings between service providers and Families SA to discuss families at risk
19. Police ensure data retention systems collate incidents involving same family to enable officers to ascertain immediately whether family has previous interactions with police or notifications to Families SA